WASHINGTON — When it comes to health care, President Trump says he’s doing “the right thing” for Americans. He's willing to work with Democrats on a bipartisan plan, he says, after at leastthree failed attempts by the Republican-controlled Congress to repeal and replace the Affordable Care Act.

At the same time, he's using the power of the presidential pen to unravel the ACA piece by piece — which could affect health care coverage for more than 11 million Americans.

It's the government's responsibility to enforce the law, just as it is for it to enforce laws that pay for the military, education or law enforcement. If the administration doesn't follow through on the parts of the law that make it work, the program could fail.

Yet Trump has consistently denied his administration is playing any role, instead blaming his predecessor, former president Barack Obama, for all of the health care law's problems. While Trump has called for the government to "let Obamacare fail" to pressure lawmakers to come to the bargaining table, his latest moves suggest he's actually serious about following through.

Trump took his most concrete step to dismantle the ACA on Thursday, as he signed an executive order that would allow insurers to sell short-term plans that don't meet the ACA. “Since I became President of the United States, I just keep hearing 'repeal and replace, repeal and replace.' Well, we're starting that process," Trump said, promising the order would be the first of many steps. But he didn't stop there.

Current law allows people to purchase short-term plans for three months, but these would cover people for up to a year. Under the order, consumers could also purchase their health plans as part of associations of small businesses or individuals and across state lines, going around Congress.

All of these devices would make Obamacare alternatives more available and attractive, which is why the law's supporters are concerned that they'll lead to the kind of bare-bones catastrophic policies the Affordable Care Act outlawed. If young, healthy consumers helping to subsidize older, sicker patients pull out of state exchanges, that will result in even higher premiums for the Obamacare plans.

Also at the heart of the problem is the administration's refusal to commit to paying insurance companies subsidies to reduce the cost of buying insurance for Americans who don't make much money, and creating uncertainty about whether the government will continue to require people to buy insurance or pay a penalty on their taxes.

The failure to do those two things sucks money out of the insurance market, meaning insurance companies have to find the money to stay in business other ways – such as raising the cost of insurance for those who can pay. And if the companies can't find the money to break even on their expenses, they could stop selling insurance in parts of the country.

Trump has also halved the time in which people can buy health insurance starting Nov. 1, cut the national advertising budget and grants for "navigators," who help show people how to buy insurance. And the federal website used to buy insurance for 39 states will be closed for maintenance for up to 12 hours every Sunday, a peak shopping day.

“It’s hard to look at that series of decisions, which is entirely in the hands of the administration, and say they want anything other than this to be a miserable failure,” Kathleen Sebelius, Obama's first Health and Human Services secretary, said.

"It reminds me of the Wizard of Oz, when the witch kept throwing out these things like flying monkeys," said Katherine Hempstead, senior adviser at the nonpartisan Robert Wood Johnson Foundation. "It's like what other thing things can we think of, what grenades can we launch at this market?"

Here's a detailed look at the ways Trump is targeting Obamacare.

The executive order

Trump says his order will make cheaper health insurance available to more consumers. For self-employed people who earn more than 400% of the federal poverty limit – about $65,000 for a family of two – it will also give them a chance to buy insurance that doesn't cover things they don't want.

Many women past childbearing age, for instance, have complained about having to buy plans that cover childbirth, says health economist Gail Wilensky, who headed the Centers for Medicare and Medicaid Services under President George H.W. Bush.

US President Donald J. Trump holds up an executive order on healthcare after signing it during a ceremony in the Roosevelt Room of the White House in Washington, DC, USA, 12 October 2017. The executive order overhauls federal regulations of the health insurance market, encouraging insurance companies to create cheap plans. Critics of the plan say that it could draw away young and healthy people from the markets created by the Affordable Care Act.(Photo: MICHAEL REYNOLDS, EPA-EFE)

But it will also cut the market in pieces, said Eliot Fishman, senior director of health policy at Families USA, which supports the law. People who need more expensive coverage will be forced into one market, while those who don't want to buy it will go into another market. That would undermine the entire system, which depends on young, healthy people paying to offset the costs of insuring those with various medical conditions.

What's more, critics say that allowing people to purchase short term plans skirts mandates for “essential health benefits” coverage such as maternity care, and discriminates against people with preexisting conditions.

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President Trump was not pleased that the Republican's effort to repeal and replace Obamacare collapsed.
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The subsidies

Before the White House's announcement late Thursday, Trump could have helped stabilize the market and lower expected premium increases by guaranteeing to pay the subsidies that insurers use to cut out-of-pocket costs for customers. He could have also emphasized that the Internal Revenue Service is enforcing the law requiring those who don't buy insurance to pay the tax penalty.

Now, however, the administration decides each month whether it will keep paying the subsidies. A report on insurance rates in 20 states by the nonpartisan Kaiser Family Foundation found that uncertainty about the individual mandate and subsidies is the biggest reason for companies deciding to raise prices.

The administration's refusal to make longer-term commitments to subsidies and the mandate is meant to cut the number of people buying insurance in the federal market, said Hempstead.

The congressional spending plan passed earlier this year doesn't include a set amount of money for the subsidies, but the money could be included in bills passed by the end of the year to pay for community health centers or the Medicaid plan for children, Wilensky said.

The White House has not participated in discussions in the Senate to fix the subsidies and reduce premiums, said an aide close to the negotiations between Sen. Lamar Alexander, R-Tenn., and Sen. Patty Murray, D-Wash., who spoke under condition of anonymity because they weren't authorized to speak publicly about the meetings.

Insurance companies will raise the cost of buying insurance for customers if they do not know for sure that they will get money from the government to make up for their overall expenses, said Sebelius. That's the main reason for higher rates, she said.

However, health care economist Wilensky noted that problems with higher rates and insurance companies dropping out of the system were happening before Trump was elected.

Funding for 'navigators'

In September, the Trump administration cut by as much as 90% the amount of money it spends on navigators, the people who help customers buy insurance. That was considered by experts as another form of sabotage.

Trump has said he wants to make it easier to buy insurance without navigators.

That can be done by relying on "trained agents and brokers" to sell insurance and making it easier to use Healthcare.gov to buy insurance, says Christopher Condeluci, who helped write part of the law as a Republican counsel for the Senate Finance Committee. Money once spent on navigators will go to information technology and people to help with the new version of the site, although Condeluci says it will not be ready until the next fall's open enrollment.

That strategy has the problem of insurance companies cutting or even eliminating brokers' commissions as a way to discourage selling ACA plans.

Many agents now will not know until a week before the open enrollment period starts if they will receive commissions or how much they will be.

Uncertainty, says Fishman of the pro-ACA group Families USA, is the only constant. "We have never experienced an open enrollment in which the administration is trying to sabotage the system," he said. "We are in uncharted territory."

11-year-old Frank "FX" Giaccio gets a pat on the back from Trump while mowing the lawn in the Rose Garden of the White House on Sept. 15, 2017. Giaccio wrote a letter to Trump expressing admiration for Trump's business background and offered to mow the White House lawn.
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President Trump, Speaker Paul Ryan and other congressional Republicans celebrate in the Rose Garden of the White House following the House vote to repeal Obamacare on May 4, 2017.
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Secretary of the Interior Ryan Zinke listens while Trump speaks before signing an executive order to review the Antiquities Act at the Department of the Interior on April 26, 2017.
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White House Chief of Staff Reince Priebus and Vice President Pence look on as Trump speaks briefly to reporters after greeting Harley Davidson executives on the South Lawn of the White House on Feb. 2, 2017.
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Trump reads from one of the executive orders he signed during a visit to the Department of Homeland Security with Vice President Mike Pence, Homeland Security Secretary John Kelly and other officials in Washington on Jan. 25, 2017.
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President Trump holds a letter left for him by former president Barack Obama as Vice President Pence looks on before the swearing-in of the White House senior staff on Jan. 22, 2017.
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